Prospective National Audit of Major Gastrointestinal Complications of Transesophageal Echocardiography Studies in Children

Background:Perioperative trans?esophageal echocardiography (‘TEE’) is widely used for the assessment of anatomy/repair of congenital cardiac defects. It is recognised that there are risks associated with its use. Aims: We wished, by means of a contemporaneous prospective national audit over a six?month period, to establish what proportion of TEE studies in children are complicated by major upper gastrointestinal or upper aerodigestive tract trauma. Methods: After obtaining appropriate local institutional ethics committee approval, a national prospective audit of the rate and severity of gastrointestinal complications of trans?esophageal echocardiography studies in anaesthetised adult cardiology and cardiac surgical patients was conducted by the Association of Cardiothoracic Anaesthesia and Critical Care in the United Kingdom and Ireland during the twelve months of 2017. During the second six months of the audit, the Congenital Cardiac Anaesthesia Network (an organisation including anaesthetists with a paediatric cardiac anaesthetic practice in all the United Kingdom cardiac surgical centres) prospectively audited the incidence of such complications of TEE studies in children. Results: A total of 1,059 studies were included in this six?month paediatric audit. There were no reports of the specified major complication. Statistical Analysis: The zero incidence of the major complication is consistent with a worst possible incidence of five per thousand TEE examinations. Conclusions: Such potentially reassuring information could be included in discussions with patients or families about the risk of trans?esophageal studies in children.

Comparison of grading of aortic stenosis between transthoracic and transesophageal echocardiography in adult patients undergoing elective aortic valve replacement surgeries: A prospective observational study

Introduction: Intraoperative trans-esophageal echocardiography (TEE) has been found to underestimate severity of aortic stenosis (AS) compared to trans-thoracic echo (TTE). We conducted a prospective study comparing pre induction TTE and intra operative TEE grading of AS in patients posted for aortic valve replacement surgeries. Methods: Sixty patients with isolated AS who were undergoing aortic valve replacement were enrolled in our study. Baseline TTE was done and after induction of anesthesia, TEE was done. Mean gradient across aortic valve, peak jet velocity, aortic valve area (AVA) by continuity equation and dimensionless index (DI) were assessed in both. Results: Mean gradient decreased from 56.4 in TTE to 39.8 mm Hg in TEE leading to underestimation of AS in 74.5% of patients (P < 0.0). Mean of peak jet velocity also decreased from 500 in TTE to 386cm/s in TEE (P < 0.01). In 76 % of patients this led to reduction of AS grade from severe to moderate. Mean AVA was 0.67 cm2 in TTE and 0.69 cm2 in TEE. Though there was 0.02 cm2 increase, it was not statistically significant (P = 0.07). All the patients remained as severe AS in TEE. DI mean was 0.19 in both TTE and TEE (P = 0.14).It led to underestimation of severity in 6% of patients in TEE. Conclusion: Our study shows that AVA measurement by continuity equation and DI are reliable in grading aortic stenosis while performing intraoperative TEE. Mean gradient and jet velocity can be significantly reduced.

Esophageal ultrasound and floating catheter in different coronary artery bypass grafting for cardiac function and pulmonary artery pressure / 局解手术学杂志

Objective To compare the cardiac function and pulmonary arterial pressure of the patients undergoing surgery of off-pumpcoronary artery bypass grafting(CABG) and on-pump-CABG by the esophageal ultrasound and the floating catheter,to find out what kind of coronary artery bypass grafting is better for cardiac function.Methods The design of this experiment used a completely randomized block design,36 patients were randomly divided into two groups:group A(off-pump-CABG),group B (on-pump-CABG),18 cases in each group.The detection time point set after all the operation had been completed.The pulmonary arterial systolic pressure,the right ventricular end diastolic volume,the right ventricular ejection fraction and the left ventricular end diastohc pressure were measured by the esophagus ultrasound and floating catheter.Results There was no significant difference in esophagus ultrasound and floating catheter between the two groups (P ＞ 0.05).The results of echocardiography and floating catheter showed that the pulmonary artery diastolic blood pressure was lower in group A than that in group B (P ＜ 0.05).The heart function in group A was better than that of group B (P ＜ 0.05).Conclusion The effect of the ultrasonic heartbeat graph and the monitoring of the floating catheter in the off-pump-CABG and on-pump-CABG are basically the same.The heart function in off-pump-CABG group was better than that of on-pump-CABG.The reason may be that the off-pump-CABG is less likely to be associated with the flow dynamics of the blood flow dynamics and the cell factor associated with the non physiological ducts.

Papillary Muscle Rupture of the Mitral Valve Caused by Traffic Accident / 日本心臓血管外科学会雑誌

A 59-year-old man was admitted to our hospital because of multiple traumas in a motorcycle accident. On admission, his vital signs were stable, however, 4 h later his respiratory condition suddenly worsened and be needed ventilatory support. Cardiogenic shock was suspected, however, the conventional echocardiograph findings were indistinct because of the presence of subcutaneous air. On the third day of hospitalization day, the Swan-Ganz catheter revealed high pulmonary arterial pressure. The subsequently performed trans-esophageal echocardiography showed severe mitral regurgitation. Therefore, semi-emergency mitral valve replacement was planned on the 5th hospital day. Operative findings showed that the anterolateral papillary muscle had torn off from the left ventricular wall and the associated strut chordae was also torn from the anterior leaflet. The post-operative course was uneventful, and the patient was discharged on the 40th postoperative day.

Tricuspid valve excision using off-pump inflow occlusion technique: Role of intra-operative trans-esophageal echocardiography.

A pacing system infection may lead to infective endocarditis and systemic sepsis. Tricuspid valve surgery may be required if the valve is severely damaged in the process of endocarditis. Although, cardiopulmonary bypass is the safe choice for performing right-heart procedures, it may carry risk of inducing systemic inflammatory response and multi-organ dysfunction. Some studies have advocated TV surgery without institution of CPB. We report tricuspid valve excision using the off-pump inflow occlusion technique in a 68-year-old man. We also describe role of intra-operative TEE as a monitoring tool at different stages of the surgical procedure. .

Anesthetic management of renal cell carcinoma that extended into the right atrium through the inferior vena cava: A case report

Renal cell carcinoma (RCC) rarely extends to the cardiac chambers, and the presence of an extension of tumor thrombus to the inferior vena cava or the right atrium has not been shown to determine the survival of patients with RCC.Although an aggressive surgical approach remains the primary treatment for RCC, the anesthetic management remains a difficult intraoperative challenge.We report here on a case of performing cavoatrial tumor thrombectomy and radical nephrectomy in a patient with RCC with an intracardiac extension, and we used cardiopulmonary bypass and intraoperative trans-esophageal echocardiography to assess and treat this tumor.

Quantification of AS and AR.

Trans-esophageal echocardiography (TEE) is routinely used in valvular surgery in most institutions. The popularity of TEE stems from the fact that it can supplement or confirm information gained from other methods of evaluation or make completely independant diagnoses. Quantitative and qualitative assessment permits informed decisions regarding surgical intervention, type of intervention, correction of inadequate surgical repair and re-operation for complications. This review summarizes the various methods for quantification of aortic regurgitation and stenosis on TEE. The application of Doppler echo (pulsed wave, continuous wave and color) with two-dimensional echo allows the complete evaluation of AV lesions.

Intra-operative trans-esophageal echocardiography in congenital heart disease.

Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.

How do I get an optimal image.

Trans-esophageal echocardiography (TEE) is fast becoming an indispensable monitoring and diagnostic modality in cardiac operation rooms. Its convenience and dependability in making important and crucial decisions intra-operatively, during cardiac operative procedures, makes it one of the most useful weapons in a cardiac anesthesiologist's armory. But to make reliable inferences based on intra-operative TEE, creation and development of a proper image is one of the fundamental requirements. The image quality can be affected by factors like patient anatomy, quality of the ultrasound system, and skill of the echocardiographer. Since the first two cannot be changed, in most of cases, we will have to work on the third factor to optimize image quality. A working knowledge of the physics of ultrasound imaging and a sufficient familiarity with the various knobs and controls on the machine will go a long way in helping one acquire an optimum image.